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the mockingbird, the cowbird and the bluebird

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Each morning as I sit on my deck drinking my coffee, I am privileged to watch the behavior of many bird species, and observe their approach to parenthood (among other things).

I see many parallels between this behavior in the wild and the approach to parenting I sometimes see in mothers and fathers of children admitted to the hospital.

OK, so you are thinking I am a little bit nuts, and perhaps that is true. But when you are always looking for topics about which to blog, this kind of thing happens not infrequently. So humor me, and see what you think about this metaphor when I am done.

Every day for the past few mornings I have observed (and heard) a female Mockingbird aggressively defending her nestlings when any real or imagined predator has wandered a bit too close for comfort. Not content to remove them from the immediate vicinity, she doesn't stop chasing them through the neighborhood until they fly away deep into the woods. Even then she continues hollering at them (and anyone else foolish enough to come close) as a warning of just how protective she is and will be. I even saw her exhibit this behavior while fighting three crows simultaneously, seemingly with little concern for her own welfare. At the end, she was victorious, the crows left, complaining all the while, and she returned quietly to her nestlings after shouting out her victory for all to hear.

Compared to the behavior of Ms. Mockingbird, I have observed closely the pair of Eastern Bluebirds who nest in a man-made nestbox nailed to the lower level of my deck. I check the nestbox frequently, reporting information about it to the Cornell University Lab of Ornithology. The Bluebirds are attentive parents, and when there are eggs or young in the nest they always stay close. However, they fly off whenever they see or hear something unusual, and certainly whenever I approach the nest site. They will sit on a tree branch close enough for them to watch me, but far enough to stay out of my reach, in case I intend to do them harm. They sit there and sing to me, imploring me (or so I imagine) not to do harm to their offspring.

Of course I am a friendly predator, and only open the nest box a little to check on the eggs or the hatchlings, and leave some food (meal worms, anyone?) nearby.

A few minutes after I go back in the house, one or both of the parents will fly to the nest to check on the contents, and usually the female will then stay inside for at least several minutes, depending upon whether it contains eggs or hatchlings.

Then there are the Brown-headed Cowbirds. These appear (if we can anthropomorphize a bit) to be quite trusting, at least when it comes to the incubation of eggs and feeding and rearing of their young. Cowbirds don't make a nest, but they run (fly) around finding other nests in which to lay their eggs. They lay ALOT of eggs, because not all of them will be accepted by their involuntary foster parents. What I have observed at my feeders is a couple of families of house finches who come to feed as a group, bringing their young with them. Some of these family groups have one juvenile who is much bigger than the others, and clearly represents a baby Brown-headed Cowbird. Usually I see the mom and dad Cowbirds in the vicinity, often at the feeder at the same time, but making no attempt to feed their own youngster, who is monopolizing the attention of the (usually) male housefinch, begging to be fed, and eating twice as much as his foster siblings.

OK, so even if this is of mild interest to you, what does it have to do with doctoring, or patients, or their parents?

Well, one of my points is that in nature there doesn't seem to be one "best practice" of parental behavior and child rearing. All three approaches seem to work, at least for the birds. The other point is that we, as physicians, often expect parents to behave in certain ways, generally consistent with our own values, beliefs and experiences.

So, lets take the Mockingbird.

How many times have we, as physicians become distressed because a mother or father of a hospitalized child seems always to be "on the offensive?" Often (in my experience) these are parents of kids with chronic or congenital conditions, who have had numerous admissions, may have been the recipient of previous medical errors, or may have simply just had a prior bad experience with the medical system.

Our students and residents and less experienced physicians may take the Mockingbird behavior personally, and become defensive.

This only enrages the Mockingbird parent even more, because they perceive a lack of team, a lack of acknowledgement of their role in the healthcare of their child. The most beloved and trusted physicians are those who have been able to form a partnership with the Mockingbird parent, who acknowledge the fear and uncertainty they feel when faced with a new set of healthcare providers, and who treat them with the respect and understanding they deserve--oh, and who refuse to allow themselves to be chased out of the neighborhood.

The other type of parent or guardian that healthcare providers tend not to "like" is the Cowbird. We tend to be suspicious of anyone who would leave their child in the hospital on their own, who would pursue their own interests while someone else tends to the needs of their child in the hospital. We may misinterpret a high degree of trust for lack of interest. We may not have taken the time to understand why the Cowbird parent only "checks in" from time to time, instead of sitting obediently at the bedside waiting patiently to be there when and if the members of the healthcare team want to share information. We may not know that the Cowbird parent has a large number of other children at home, might be a single parent, or has a job from which he or she might be fired if too many days are missed. Many inexperienced physicians can interpret this lack of presence as lack of caring, and may fail to make the attempt to communicate with the Cowbird parent.

Finally, the Bluebird.

In my experience most of us find the Bluebird parent to be the epitome of "perfection." Always close by but never aggressive. Always willing and able to provide bedside care, but never in the way. Generally the Bluebird parent is less likely to argue with healthcare providers, and more likley to take our advice, or agree to whatever test or treatment we have suggested. They may ask questions but are always polite. These are the parents who say thank you every day, they make us feel good when we go in the room, so we want to go in more often, spend more time with Mr. and Ms. Bluebird, AND their offspring.

Which parenting approach (with regard to a sick or hospitalized child) is best? If we take a clue from nature, we would have to say they are all effective approaches to continuation of the species. As physicians we need to understand that these differences exist (plus many others) and that it is not up to us to judge the validity of one over the other.

Now I am not suggesting that we tolerate child neglect, or condone parental behavior that is so aggressive as to be physically, verbally or psychologically threatening to healthcare providers.

But I am suggesting that we learn to understand the motivations of all parents, and find ways to partner with them in an effort to make ourselves most effective in treating illness and facilitating wellness in their children.

So what do you think? Am I crazy?

If you are a parent of a child who has ever been hospitalized or had to seek emergency care, do you see yourself as a Mockingbird, as Bluebird or as Cowbird, or have I completely missed the boat here?

Likewise, if you are a physician, a nurse, or other healthcare provider, do you recognize the different types of parents I have described here? Are there others I should have mentioned?

Remember, I am not a vet, I am not an expert in animal behavior and only know what I have personally observed. There may be other species that would fit the metaphor better.

I would love to hear any comments or stories you would like to tell.

Recent Comments

Alice,
wow, great metaphor. I definitely have seen all 3 types of parents. I think as a parent, I can actually understand the mockingbird much better than the cowbird because I know that if I believed someone intended MY child harm I would fight them without regard to my own safety! I think physicians/residents/students who don't have their own children probably have a lot harder time relating to the mockingbird style.
By the way, I just signed up for that Cornell Ornithology survey and am hopeful it will be something fun for me and my family to do together.

Oh, I'm definitely a mockingbird myself, but you probably would have guessed that. Once I identify something/someone as my "baby" whether its my own child, one of my patients, or "my" children's hospital, I do become fiercely protective. Just try and get in my way, Hah!

I am in between a bluebird and a mockingbird...depends on the relationship and trust between myself and the person helping my child. The doctors I have formed the best relationships with are the ones who understand how much I do at home on my own for my daughter and they take my suggestions and ideas for her care without brushing me aside...and likewise I trust them completely when they have to make decisions for her.

I like this quote:

"The most beloved and trusted physicians are those who have been able to form a partnership with the Mockingbird parent, who acknowledge the fear and uncertainty they feel when faced with a new set of healthcare providers, and who treat them with the respect and understanding they deserve–oh, and who refuse to allow themselves to be chased out of the neighborhood."

As one who lost a beloved child 20 years ago after his sweet life of seven years, and as a birdwatcher myself, I loved your analogy. I also appreciated your deep understanding of how even the cowbird sometimes has needs unseen by others to care for other young, perform other duties, etc. I was a mockingbird in the early years of my son's frequent hospitalizations; in the final years, as I tried to balance life at the hospital in another state with life three hours away at home, I probably became more of a bluebird and occasionally was forced to be a cowbird. The bluebird role for the most part is a good one, although in retrospect I have to say that there were moments in those final years when I should have let the mockingbird back in. In saying that, I mean that I wish I had known more then about patients' rights and about palliative care. Considering what he endured (a rare hereditary disease), Andrew had a good though short life with parents and providers who loved him. But palliative care might have given him a softer pillow for his journey...
As a postscript, I have to always smile about the mockingbird. I got to know one well on the Gulf Coast after Katrina: we worked out of a trailer for one long spring, a trailer parked unfortunately close to a lone remaining shrub in the flattened town of Biloxi. A mother mockingbird succeeded in raising a brood in that shrub and everytime I left the trailer, she nosedived me! Yes, the mockingbird is quite fierce:)

Marjie, I am sorry for your loss, and know that you remember many of the moments your child spent in hospitals and healthcare settings, especially those that were less than family friendly or child-centered, as well as those moments that WERE able to meet all your needs. Do you have any ideas about HOW we can educate our students and residents to help them understand the needs of the family? Or about how they can learn to understand better the mockingbird mom (or dad) in whom the need to nosedive healthcare providers might be genetic?

Dr. Ackerman, to continue your analogy, I guess my position now would best be described as an owl, quiet and watchful but (with age) respectful of others’ territories. Thus, I feel that as individuals the students and residents in this and recent generations have learned to assess the patient with a great store of empathy.

But when Andrew was alive, over 20 years ago now, there were two incidents in particular that were not so positive. The first was when the physician, a researcher at a hospital down the road, and his residents came into my infant son’s room to tell me that, while they knew little about the disease, his condition was terminal. I was there alone that day, and scared, and had to relay that information to my husband and our families myself. That was no one’s fault, but the diagnosis/prognosis came so quickly and chillingly even though we expected worrisome news. The other incident did not seem negative at the time, and certainly is a measure of the progress in research that our institutions have made over two decades-plus: we were desperate for any measure that might help Andrew and when an investigational drug was offered, we jumped on it. What I’m less sure of in retrospect is that I recall only minimal explanations about the drug, and moreso, it appeared helpful at least to a small degree yet suddenly was removed with little explanation. Again, this was at a hospital in another state, and the researcher now is rarely involved in the study of this disease – I know this because I have followed his studies, not from any personal contact: I never heard from him again after Andrew passed. Now, working in the field, I know that our researchers will carefully inform the family of all parameters of the research through the consent process, and that the family will remain in the loop throughout the study. And it would help during research if the family members are definitely mockingbirds!

However, positive incidents can also be instructive, and there were so many during Andrew’s life: every single nurse was gentle, and often seemed as touched by Andrew’s sweet and funny personality as we were by their caring. When we first received his diagnosis, our family physician got on the early internet to research articles, as did a cousin, a pediatrician at that time at Mass General. Their lit searches were quite informative. The child life staff was beyond belief; every day, they were there to play with him, talk to him, watch his favorite movies with him (Top Gun, Ferris Bueller’s Day Off:). I was so delighted to see a child life staff here, too! Because of child life, Andrew got to meet everyone from NASCAR drivers to Dan Ackroyd, and he remembered every detail of those visits.

Frankly, I may have blocked out some of the more difficult moments in the course of Andrew’s disease. But by referring to the need back then for palliative care, I’m talking not so much about Andrew but about ill children and their families in general. In an odd way, I know we were fortunate to have been educated, have friends and family in medicine, to feel empowered to ask questions, etc. Due to income and circumstance, we were also fortunate to have been able to be mockingbirds as much as we were. But the average family member often is not as educated, or as confident about asking questions; by observation, I can tell you that they often are both frightened and intimidated by the very fact of their child being in a hospital. The language of medicine (from MRIs to ‘sticks’) is often a foreign one to them. The noise, the smells, the unknowns: these need guidance from a professional with compassion and a gentle nature. In the more difficult circumstances, someone to explain options for palliative care could bring peace to family and child.

The nose-diving mockingbird comes with the territory. We must protect our young. But students and residents might want to pick up a few extra skills during pediatric rounds, such as being deft and able to deflect (with kindness) sharp talons, and most importantly, the ability to communicate and follow up with clarity and empathy.

I do have one more memory, an important one; though it may be common practice, it was extraordinarily meaningful. Andrew had made friends with Dr. Simon, the chair of the department, over the years. In Andrew’s final moments, Dr. Simon brought in his residents and they stood to the side, with respect and reverence, as we said good-bye to our son. Dr. Simon, too, was an owl.

Marjie, your story is so compelling and so enlightening. Thank you for sharing. I hope that I, too, can be an Owl when I am supervising others, although sometimes it is difficult for me to stand back and not do what I know how to do as I allow others to develop their expertise with difficult situations. Thanks for pointing out some of the ethical issues that surround using experimental drugs in children. Yes, we need to fully explain all possible effects of a drug--both good and bad. Students, residents, and even experienced doctors need to learn how to communicate in an open and understandable way. It is often difficult to get the students to talk about tests and results in real words, and not the typical medical shorthand we use all the time (as you pointed out). Patients are PEOPLE; their families are PEOPLE, and they deserve to be treated as such.

Once again, than you for taking the time to write, and for publicly reliving some painful moments from your past. I am sure I would have found Dr. Simon a kindred spirit. And I love owls.

Thanks, Gretchen. Your perspective is so important. It can sometimes take years for us medical folks to learn that we have an awful lot to learn about children who are chronically ill, or who have congenital problems. YOU are the expert on YOUR child, even if we are usually the expert with regard to the medical and scientific facts.

Putting a stethoscope on a child and doing an a thorough exam are incredibly important, in learning what may be wrong.

Just this past weekend, I had a resident tell me he didn't want to wake the child up to do a neurological exam. Sometimes that is OK, but THIS CHILD WAS ADMITTED WITH AN ACUTE NEUROLOGICAL PROBLEM. That behavior brings out the mockingbird in me, really fast.

I would agree with Heather that I am somewhere between the Mockingbird & the Bluebird. I would also qualify that with: I am a Bluebird with docs/residents/students who: 1.Listen to me with regard to what is typical of my child, what the reason is that I am there & how we usually treat my child. 2. EXAMINE my child- e.g. Hands & stethoscope on (you'd be surprised at how many do not). 3. Explain what they think, what they'd like to do & WHY if it is a change from what has worked in the past- & it helps if they accurately assess that I don't need them to "dumb it down" for me. 4. Give me a minute to process the plan, ask questions, and decide to move forward.

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About Dr. Ackerman

Alice Ackerman, MD, MBA, FAAP, FCCM is the Chair of the Department of Pediatrics at Carilion Clinic and Professor and Founding Chair of Pediatrics at the Virginia Tech Carilion School of Medicine. Dr. Ackerman is recognized nationally as an expert in pediatric critical care.

She has been at Carilion Clinic since June of 2007. Her primary goals are to enhance the health care of children in the Roanoke Valley and Southwest Virginia, and is actively working to do this both as physician in chief of the children's hospital, as well as through involvement with many state-wide initiatives.